Provider Demographics
NPI:1811103492
Name:HANSEN, EMILY R (DPT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:R
Last Name:HANSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:R
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:27 DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2601
Mailing Address - Country:US
Mailing Address - Phone:860-274-4092
Mailing Address - Fax:860-274-4099
Practice Address - Street 1:44 DALE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3612
Practice Address - Country:US
Practice Address - Phone:860-674-1713
Practice Address - Fax:860-674-1848
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008026225100000X
CT9508225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080008026CT01OtherANTHEM BCBS
CT650001438Medicare PIN